Reset Button for DSM Diagnosis? (Part 2)

This obviously is the second part of the part I put up a couple of days
ago: href="http://scienceblogs.com/corpuscallosum/2009/04/reset_button_for_dsm_diagnosis.php">Reset
Button for DSM Diagnosis? (Part 1).  It may not make much
sense unless you read the first part.



In order to understand the idea behind the use of the FFM, instead of
the current diagnostic criteria, it helps to look at an
illustration.  Although the original journal article is viewable
by registration only, it appears that the pop-up illustration can be
viewed by anyone who has the URL.  I think href="http://ajp.psychiatryonline.org/content/vol166/issue4/images/large/U310F1.jpeg">this
will work.  At least it works when I view it in Opera, which
does not have access to my Firefox cookies, and should not know that I
am registered. 



Some of what I was going to add has already been added by a commenter,
dreikin.  In fact, dreikin went into greater detail than I would
have, so that is done.  I would, however, elaborate on the
question of whether the scales used in the FFM are
"biologically-based."  How could anyone know this?  They may
"know" because of particular correlations in various studies.  But
I hardly think that I need to say, that such correlations are open to
interpretation.  Besides, to we really care if they have a basis
in biology?  If so, why?



One of the main themes of the article is that any changes to the
diagnostic system should be based, at least partly, upon utility. 
That is a good idea.  But the DSM serves multiple purposes, so the
concept of utility can get muddled.  It is important to ask:
useful for what? and useful for whom?



The authors state:

However, one significant issue seldom examined is whether
the FFM will be clinically useful. Clinical utility means the extent to
which a diagnostic system assists clinicians in fulfilling key clinical
functions, including making treatment plans and prognoses,
communicating with patients or other clinicians, and describing a
patient's global personality or important personality problems.

That is valid, as far as it goes.  It does, howver, leave out the
most important item: would the implementation of the FFM improve
patient outcomes?

Back when I would occasionally host medicla student journal clubs, I
would let the student present the paper, then see what questions came
up, then, when the discussion seemed to be losing steam, ask the
question: How would you use this information in clinical practice?



Usually, several of the students would look surprised.  I, in
turn, would be surrised that they would be surprised.  It seems
like a fairly obvious quesiton.  The whole point of reading the
literature is to put it into use, and generate better outcomes. 



The FFM could, if properly implemented, lead to some advantages. 
It could lead to greater standardization of the diagnostic
process.  This, in turn, could lead to higher interrater
reliability.  In research settings, it could lead to a more
homogeneous patient population. 



Of greater interest, though, is what the author mentioned about the
treatment planning process.  There always will be heterogeneity,
even within a diagnostic category.  Individuals often will have
characteristics of more than one personality disorder.  By looking
at the individual scales, it would be possible to propose interventions
for each of the areas where pathology may be present.  This
should, in theory, lead to greater individualization of the treatment
plan.  Again, in theory, this should lead to better
outcomes.  It may also lead to some degree of face validity, which
in some cases might improve motivation and compliance.  This
realtes to another of the authors' points, that it could improve
communication with patients. 



So long as I am venturing into speculation, I'll go a bit
farther.  It is possible that the use of the FFM could
destigmatize the diagnostic process.  By having greater
transparency in the process, it is possible that treaters and patients
can focus more on the problem areas, and less on real, implied, or
perceived value judgments.



The importance of the this is illustrated, perhaps inadvertently, by
the first comment to the first part of this series.  If the DSM is
used as intended, there is nothing about it that is judgmental. 
The problem is, there does not appear to be any way to separate
diagnosis from judgment, in most people's minds.  Perhaps this is
wishful thinking, but if the process is made more transparent, perhaps
some of the implied value judgments would go away.